Section 9: Tobacco and Alcohol Use Flashcards
Tobacco
- Single largest preventable cause of morbidity and mortality
- Smokers lose -10 years of life
- Smokers suffer more health problems and disability
Health effects of modern cigarettes
- Inc. risk of lung adenocarcinoma, most common type of lung cancer
- kills 1 one of every two people who use them
Smoking leads to or causes:
- Diabetes
- Rheumatoid arthritis
- Impaired immune system/immune function because some chemicals damage the immune system
- Reduced quality of life
- Problems with reproduction in men and women
- Slower wound healing
- Tuberculosis disease
- Ectopic pregnancy, preterm delivery stillbirth, sudden infant death syndrome
- Cleft lip and cleft palate (if smoking while child is in utero)
- Erectyle dysfunction
- Age-related macular degeneration
- Failure rate of treatment for all cancers
- Risk of bone fractures
- Muscle aches and pains
Key drug in addiction to cycle of tobacco products
Nicotine
Smoking cessation benefits
- Immediate quitting: cut heart attack risk by 50% vs non quitting
- 1 year: heart disease risk is 50% of a non-smoker
- 2-5 years: risk of stroke approximately same of non-smoker
- 10 years: risk of lung cancer reduced by 50%
- Quitting at 30 years: gains 10 years life expectancy
- Quitting at 60 years gains 3 years of life expectancy
Tobacco Cessation
- Most people who quit smoking do so without evidence based tx. But cold turkey is the least effective in long term.
- 50% will resume within 14 days
- 75% will resume within 30 days
- Only 5% will be able to quit without assistance
- There are more former smokers than current smokers today
Lung Cancer Screening
Screen those with following criteria:
- Greater or equal to 30 pack year smoking history
- Current smoker or quit within past 15 years
- Between age of 55-80 years of age
10 Key recommendations from USPHS Guidelines
- Clinicians need recognize that tobacco dependence is a chronic disease and should be treated and appropriately followed up
- Should consistently assess and document tobacco use
- Txs are effective across broad range of population
- Brief tobacco dependence tx is effective
- Individual, group, and telephone counseling is effective (more intense intervention, more effective). Person to person of more than 4 sessions appears to be especially effective.
- Numerous effective meds exist
- Combination of counseling and meds is more effective thatn either alone
- Telephone “quitline” counseling is effective.
- If user is not ready to quit, use motivational interviewing skills to increase future quit attempts.
- Tobacco dependence tx are clinically effective and very cost effective vs other tx for other disorders
Pharmacotherapy Guidelines
Use effective meds except:
- Tx is contrindicated
- Special populations where there is insufficient evidence (pregnant women, smokeless tobacco users, light smokers, adolescent)
First Line Medications
- Patch alone: 45% tobacco free at 8 weeks
- Lozenge alone: 40% tobacco free at 8 weeks
- Nicotine replacement inhaler or nasal spray (prescription only)
Varenicline: the most effective monotherapy (51% tobacco free at end of 12 week program, 35% tobacco free at 6 months
(it’s a nicotinic receptor partial agonist, meaning, binds to the same receptors as nicotine. Hence prevents withdrawal but stops nicotine highs.
Bupropion: 40% tobacco free at 8 weeks (inhibits reuptake of norepinephrine and dopamine
Treatment combinations
Combination of Varenicline and bupropion is the MOST EFFECTIVE treatment
- Combination of bupropion patch and lozange
- combination of bupropion and lozenge
Combination of varenc
Treatment combinations
Combination of Varenicline and bupropion is the MOST EFFECTIVE treatment
- Combination of bupropion patch and lozange
- combination of bupropion and lozenge
Combination of varenicline, bupropion and nicotne replacement therapies only preliminary data is available
Tripple therapy is recommended:
- Bupropion, patch and nicotine replacement therapy
Two second line meds (off label)
- clinidine and nortriptyline (if first line meds have not worked or contraindicated)
- Light smokers (<10 cigarettes per day) show NO SIGNIFICANT BENEFIT from nicotine replacement therapy
Bupropion will not prevent weight gain
Treatment in special populations
If with Mental illness:
- May need higher doses, longer duration of tx, combination of meds
BIPOLAR:
- DO NOT USE bupropion
- Patch is RECOMMENDED TREATMENT
SCHIZOPHRENIA
- Patch is RECOMMENDED
CARDIOVASCULAR DISEASE
- No association between nicotine patch and acute cardiovascular events
- Use CAUTION in px with cardiovascular disease when using nicotine replacement therapy
PREGNANT SMOKERS:
- Counseling is best
- Bupropion and varencicline: FDA category C for use during pregnancy
- Prescription nicotine replacement therapy: Category D with potential risk of birth defects
Duration of treatment
- Long term nicotine replacement has no known health risk
- Bupropion is approved for up to 6 months
- Varenicline can be used up to 6 months
e-cigarettes
- Not FDA regulated
- “no nicotine” have been found to contain nicotine
- Contains less harmful chemicals compared to tobacco. but still contains heavy metal
- Associated with EVALI (E-cigarette or Vaping product use Associated Lung Injury)
5As for Tobacco Cessation
ASK: Identify tobacco use and document px
ADVISE: advise px
ASSES: is px ready to quit?
ASSIST: Provide counsel for those who are ready
ARRANGE: schedule follow up
Alternative:
ASK, ADVISE, REFER
- Use motivational interviewing to increase future quit attempts
Alcohol Consumption
Moderate:
- 1 drink per day for women
- 2 drinks per day for men
Binge drinking:
- Drinking enough that blood alcohol level increases to 0.08 mg/L
- 5 drinks in 2 hours for men
- 4 drinks in 2 hours for women
Heavy Alcohol Use:
- Binge drinking on more than 5 days in the past month
- More than 4 drinks on any day for men
- More than 3 drinks on any day for women
At risk drinking:
- Exceeds levels above for any day or week
- Binge drinking at least once a month
- Drinking that increases risk of future problems
Alcohol Use Disorder
- More appropriate term because it’s a continuous spectrum
- “alcoholism” and “alcoholic” no longer used. Stigmatizing and imprecise.
Most common symptoms of AUD
- Significant distress or impairment
- Impaired control over use
- Cravings and preoccupations
- Persistent but unsuccessful desire to quit or cut down
- Use despite adverse consequences such as hangover, nausea, heartburn, depression, and other health problems
-10% of people with AUD develop serious adverse consequences, including job, legal, and role failure problems - The most severe 10% are over represented in rehabs, jails, and hospitals
DSM 5 for AUD
- Drank too much/long than planned
- Tried quitting, but couldn’t
- Spent lot of time drinking, took long to recover from hangover
- Wanted drink badly, couldn’t think of anything else
- Drinking interfered with family, school, or work
- Continued drinking despite causing problem with family/work
- Stopped hobbies in order to drink
- Caused you to do harmful things (unsafe sex, walking in dangerous street, etc)
- Continued drinking despite knowing it makes you feel depressed/ black out
- Had to drink more in order to get effect
- Withdrawal symptoms
AUD Diagnostic criteria
0-1: criteria met; no AUD
2-3: mild (similar to DSM-4 alcohol abuse)
4-5: moderate (similar to DSM-4 alcohol dependence)
6+: severe
Clinical process for screening
- Annual prevention
- High risk groups: young people, high risk regions, trauma/STD, family history, pregnant or planning to be pregnant, heavy smokers, clinical suspicion
- Oral survey: ask px how many times drink:
1. Number of drinking days per week
2. Number of drinks per day
3. Advice should be gibve to reduce or stop if not in moderation drinkling - Alcohol Use Disorder Identification Test (AUDIT) (available online)
- It is the recommended screening test
5-10: at risk
11-15: more at risk
16+: high probability of moderate or severe AUD
AUDIT-C
Rated 0 (low number of occurrences) to 4 (daily, high number of occurrences)
- How often do you have drinks containing alcohol?
- How many drinks containing alcohol do you have on a typical day when you are drinking?
- How often do you have six or more drinks on one occasion?
If score more than 5, may indicate hazardous or harmful drinking.
(Men more than 4, women more than 3)
Alcohol Misuse Interventions AT RISK DRINKERS WITH MILD AUD
Signs and Symptoms:
- exceed 5 or more drinks per drinking occasion at least monthly
- One to three symptoms of AUD
- Risk increases with intensity and frequency of drinking
- Primary risks: AUD development, liver disease, and marital problems
What to do:
- brief advice to reduce
- Naltrexone 25-50mg by mouth, as needed at time of drinking occasion
- Follow up booster sessions to improve effectiveness
Resource: “Rethinking Drinking”
Alcohol Misuse Interventions MILD TO MODERATE AUD
Symptoms:
- Going over limits
- Desire to cut down
- Use despite adverse consequences
- Tolerance
- Usually occurs as an isolated episode, possibly lasting 3-4 years, then resolves
- Similar to functional depression
Management:
- Primary care setting, not an addiction clinic
- Behavioral health
- Anti relapse medication (as effective as addiction counseling, similar effect size as SSRI antidepressants)
Alcohol Misuse Interventions SEVERE RECURRENT AUD
Risk factors:
- Family history
- Early childhood neglect
- Behavior problems in childhood
- Early onset
- Chronic or recurrent course
- Other substance abuse and psychiatric disorder
Treatment:
- Counseling
- Anti relapse medication
- Lifestyle intervention may be difficult due to the level of impairment
- REFER to an addiction specialist especially if there is life impairment and px is not compliant or initial intervention not effective
Lab Test to Track
GGT (Gamma-glutamyl transferase)
- Helpful if initially elevated
Anti Relapse Medications
First Line:
- Naltrexone 50mg by mouth daily or twice daily
- Acomprosate - modulates glutamate neutrotransmission
Second line meds:
- Disulfiram 250mg by mouth daily (inhibits aldehyde dehydrogenase)
- High rates of non compliance, not more effective than placebo
- Gabapentin 300-600mg by mouth 2 or 3 times daily
- Well tolerated, but there’s concern for possible abuse potential
- Topiramate 100-150mg by mouth twice a day
- Off label
US Standard Drink Size
12 oz - 1 beer
5 oz - table wine
1.5 oz - shot
Excessive alcohol ass. with
10% cancer, 20% intentional injuries. 7% deaths (road crash, cancer, suicide)
